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Feds Hopeful Hispanics Will Respond As Open Enrollment Comes To A Close

NPR Health Blog - Sat, 01/30/2016 - 2:58pm
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Iris Galvez, a health insurance navigator (right) helps Mary Soliz of Houston, Texas, sign up for her first health plan through the Affordable Care Act on January 28, 2015 at a Houston community center.

Courtesy of Iris Galvez

There's football season, hunting season, and the holiday season. Overlapping all of these is something decidedly less fun and sexy: open enrollment season for health insurance.

"We've been busy this past month," says Iris Galvez, a health insurance navigator with the Houston social services agency Change Happens!

Galvez helps people navigate the website and enroll in health plans offered through the Affordable Care Act marketplace.

"It's the holidays, that makes it hard. Because people are like 'Well, we'll just put it off,' " Galvez says with a laugh. "But now we're getting very busy."

Earlier this month, Galvez helped Elisia and Cipriano Saenz, a couple from north Houston, select a plan with Molina.

"You'll have to pay this much per month to Molina," Galvez explains in Spanish, before handing over a summary sheet listing the couple's monthly premium payment ($363), the federal subsidy ($691), deductible ($2,000), and copays ($20 for the primary care doctor, $55 for a specialist).

"They're pretty good, reasonable," Saenz says of the amounts. "We'll be able to afford it."

Elisia Saenz thanks Galvez for her assistance.

"You made our day," she says. "Because we were having a hard time getting in to it."

Last year, her husband Cipriano Saenz did try to sign the couple up, but he was confused, and then suspicious when a government worker requested more paperwork and asked him to confirm his Social Security number.

"Sometimes we have to be careful who we talk to, give our Social Security, ID number," Saenz explains. "He told them 'I'm very sorry. I can't give my information to you all through phone.' "

Elisia Saenz says he never followed up, and the insurance lapsed.

"Something had gone wrong, or maybe he didn't understand," she says.

Signing up can be a chore. You need to gather financial documents and set aside money for the monthly premium. Not only that, it's just unpleasant to think about risk and injury and disease.

Galvez noted that some of her returning clients were angry this year because the insurance networks had become narrower. Almost all the coverage plans on the exchange in Houston are now HMOs.

"This year they have taken away the PPO. So a lot of people are not pleased with that," Galvez said.

That means they have fewer choices of doctors and hospitals. Still, she tries to focus on the positives – not only avoiding the federal tax penalty for not being covered (which is either $695 for each adult without coverage or 2.5% of household income), but also the peace of mind that insurance will bring.

"You never know, you know? You fall and slip and break your leg, that's a big bill from the hospital," she says.

Elisia Saenz is 56 and Cipriano Saenz is 62. They work as janitors at a charter school, where Elisia also works in the kitchen. She says they can't afford the insurance offered at the school.

"It's been years that I haven't been to a doctor," Elisia says. "Thank God that I haven't gotten sick. Now I can just go and get a whole physical, and he can do the same. So we're happy that we got this."

The Obama administration has increased its outreach this year to Hispanics, running special ads and targeting cities like Houston, Miami and Dallas with big Hispanic populations.

Across the country, 20.9 percent of Hispanics are uninsured in the U.S., compared to 12.7 percent of blacks and 9.1 percent of whites, according to the Kaiser Family Foundation.

There are lots of reasons why. Hispanics are more likely to work in jobs that don't offer health benefits. Many are ineligible for the Affordable Care Act, or just don't know about the options available.

Of the three states with the biggest Hispanic populations, only one, California, has chosen to expand Medicaid to low-income, uninsured adults. Florida and Texas have not expanded Medicaid, and that's affected many low-income Hispanic adults.

In surveys, Hispanics explain the main reason they are uninsured is cost. Health coverage just seems too expensive to fit into a budget.

"They don't make enough money where they work, or they work self-employed, cutting yards and stuff," says Elisia Saenz, describing some of her neighbors.

"Sometimes they can barely, probably make it to pay the rent, feed their kids, clothe them. I know it's kind of hard for them, if it's just one person working in the household."

Federal officials counter that's an outdated perception for some Hispanics – because under the new law, many would qualify for subsidies to buy insurance, just like the Saenzs did.

Enrollment in most states for 2016 ends Sunday.

This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.

Copyright 2016 KUHF-FM. To see more, visit KUHF-FM.
Categories: NPR Blogs

Before Zika Virus, Rubella Was A Pregnant Woman's Nightmare

NPR Health Blog - Sat, 01/30/2016 - 5:23am

Diane McMenamin, 14, gets vaccinated against rubella at a high school in Willingboro, N.J., in 1976.


Before the Zika virus outbreak, which appears to be associated with serious birth defects in babies in Brazil, there was rubella, also known as German measles, which terrified the pregnant women of my mother's generation.

In the 1964-1965 rubella pandemic, an estimated 50,000 pregnant women in the United States were exposed to rubella in pregnancy, resulting in miscarriages, stillbirths, and 20,000 babies born with congenital rubella syndrome, which caused blindness, deafness, brain and heart damage. At the height of the pandemic, an estimated 1 of every 100 babies born in Philadelphia was afflicted.

A vaccine for rubella was introduced in the 1970s, so parents no longer have to live in fear. But I still remember David, my first-grade friend Kathy's little brother. Kathy's mom came down with rubella while pregnant and David was born mentally retarded. He never learned to speak, but would flap his hands and burble excitedly in the doorway when Kathy and I were playing Barbies, then flit away. As an adult, I met Kathy again. She told me David died and her face crumpled.

So far the link between Zika virus, brain damage and microcephaly is suspected, not proven. But because Zika appears to be one of the few viruses that can be transmitted from a pregnant woman to a fetus, scientists are looking at what we already know about other viruses that pass the placental barrier as well, including rubella and cytomegalovirus (CMV), to see if it can be used to help combat Zika.

"That is why I'm interested in joining the effort in finding out if Zika is truly the cause of these effects," says Dr. Sallie Permar, a pediatric infectious disease specialist at the Duke Human Vaccine Institute who studies these viruses.

I talked with Permar about what's known about rubella, Zika and the other viruses. The conversation has been edited for length and clarity.

How did scientists figure out that rubella was causing miscarriages and birth defects?

Rubella virus was early on recognized to cause fetal disease. Often there were outbreaks of rubella virus in the summer months. The waves of rubella epidemics were followed by the birth of children with long-term neurological deficits.

I can imagine it was very terrifying to be pregnant when it spiked.

How do the viruses pass from the mother to the developing fetus?

Exactly how these viruses cross the maternal-fetal barrier is still not yet understood. There are very few viruses that are known to cause congenital infections. Although we think of the immune system as usually blocking viruses, there have been some hypotheses that the mother's antibody response may actually work in opposite ways; that if the antibody does not fully neutralize the virus it may actually help in carrying the virus across the placental barrier.

Do these viruses pass from mother to child in the same way?

They have similarities and they have differences. The modes of transmission of HIV and cytomegalovirus are similar so that they can be passed to the fetus during pregnancy, during delivery, when the baby is exposed to the virus in the birth canal or through breast milk.

One thing that is very different between HIV and CMV, we know that any time an infant gets HIV, that's a pathogenic infection. If a fetus becomes infected with CMV during pregnancy, it can lead to neurologic deficits. However, if a baby gets infected during delivery or after birth via breast milk feeding, that is usually totally asymptomatic.

Does it matter when a woman gets infected?

We often don't know when congenital infections are transmitted. Likely when the mother is infected could affect transmission, but it is going to be different with every pathogen. Some neonatal pathogens hit hardest around delivery.

Why is everyone routinely given the vaccine for rubella?

In adults and children, rubella causes fever, maybe some rash; it really was the sort of a childhood illness that was mild and would go away on its own. So the vaccine was not introduced to stop the mild febrile illness but to interrupt the congenital transmission. It's an altruistic vaccine. You are protecting the mother to protect the fetus.

What people say is when the rubella vaccine came out, schools for the deaf and blind had to close because there weren't enough children to attend them. It really is a story of such success. We've sort of forgotten why vaccines are so important.

Wendy Wolfson is a science writer in Orange County, Calif.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Variations In A Gene Provide Clues About Schizophrenia

NPR Health Blog - Fri, 01/29/2016 - 5:45pm

C4 proteins (green) are seen at the synapses in a culture of human neurons. (Heather de Rivera/McCarroll Lab/Harvard via AP)

Heather de Rivera/AP

Schizophrenia might be linked to a gene that tells the immune system to destroy too many connections in the brain, according to the results from a massive gene-focused research effort.

Scientists at Harvard University and the Broad Institute studied the genomes of 64,785 people around the world and found that those with the debilitating psychiatric disease were much more likely to possess mutations of a common gene, according to the findings published this Wednesday in the journal Nature.

People with schizophrenia — more than 21 million worldwide — tend to have less gray matter and fewer connections in their brain than healthy peers. But scientists aren't sure why. The research, for the first time, suggests that variations in a gene called complement component 4, or C4, for short, could be important. The gene had previously been known to help the immune system target infections.

A mutant form of the gene makes proteins that tag an excess number of brain synapses for destruction. This explanation meshes neatly with the tendency of schizophrenia to arise during adolescence, a period during which even healthy brains are busy pruning lots of connections.

Today schizophrenia patients are treated with antipsychotics, which can help reduce some symptoms but don't address the underlying disease or its related cognitive impairment. But the identification of a key genetic factor, may help the search for therapies. Of course, the path from a gene to an effective drug is long and not guaranteed.

Neuroscientist Beth Stevens, one of the authors on the new paper, is an associate professor of neurology at Harvard and a 2015 recipient of a MacArthur Foundation "genius grant." I talked with Stevens about the work. Here are highlights from our conversation, edited for length and clarity.

What has made the search for the causes of schizophrenia so challenging?

We knew about the region for a long time based on genetic-association studies. But there are a lot of genes there, and no one gene had been identified as explaining this risk before. When [co-author] Steve [McCarroll] came to me with preliminary data to support the genetic link with C4, I was very excited because my lab had been studying the role of other immune-related proteins in brain development—in particular synaptic pruning. We had made some progress in understanding what proteins do in normal development. And given that schizophrenia is thought to be a neurodevelopmental disorder, this is really exciting. With the evidence that there was some synaptic loss, it led to the hypothesis that maybe this genetic link could be related to pruning. We were also fortunate enough to bring in a third lab, Michael Carroll, who is an immunologist who has been studying C4. So to really make progress in a question like this, it takes that kind of an interdisciplinary approach.

Is C4 involved in normal, healthy synapse pruning as well?

We know it's necessary for pruning the developing mouse brain. But we do not know [about its role in humans] like we know for the mouse.

With the involvement of the immune system in this synapse pruning, could schizophrenia be classified as an autoimmune disease?

No, this is not autoimmune. What this is showing us is that a gene that happens to be an immune system gene is involved. The last decade has shown that there are a lot of immune-related genes that are expressed in the normal healthy brain. They're repurposed in the brain to do important things—during development especially. And we have evidence that this is a gene and a pathway that is expressed in the brain and is playing a normal role in the brain.


What do these findings suggest for new treatment possibilities for schizophrenia?

Understanding how this pathway normally works in the developing brain will give us new insights into developing therapies. You have to be able to manipulate things in a specific way, in the right place—and that's not an easy thing to do, especially during development.

Are there drugs that could be applied or reworked to treat schizophrenia on this genetic level?

Emerging work from my lab and others is suggesting that this pruning pathway may be a more general process that could lead to synaptic dysfunction and loss in other diseases. The hope is if we understand its role in schizophrenia, it could provide insights into other diseases. For example, in other neurodegenerative diseases there may be some common pathways.

Do you think that some day, knowing about this aspect of schizophrenia, the disease could even be prevented?

There's a clear need for biomarkers in schizophrenia and other diseases. You really want to catch them early and think about early treatments. We're looking into ways to find biomarkers. That's something that I think will make a huge impact.

Katherine Harmon Courage is a contributing editor for Scientific American and a freelance journalist. Her next book, Cultured (Penguin Random House, 2016) is about the microbiome and diet. Follow her on Twitter: @KHCourage.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Dog Flu Virus Spreading Across The United States

NPR Health Blog - Fri, 01/29/2016 - 4:30pm
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Kelli Fabick of Ellisville, Mo., held her mother's Australian silky terrier, Zoey, as veterinarian Sarah Hormuth gave the dog a flu shot last April. The dog flu strain H3N2 is now circulating in more than two dozen U.S. states.

St. Louis Post-Dispatch/TNS via Getty Images

When Elizabeth Estes's dog, Ollie, started coughing last year, she didn't think he was seriously ill at first. But then the 3-year-old Jack Russell-chihuahua mix got much worse.

"All of a sudden, he couldn't breathe and he was coughing. It was so brutal," says Estes, who lives in Chicago. "The dog couldn't breathe. I mean, could not breathe — just kept coughing and coughing and coughing and gasping for air."

Ollie, it turned out, had caught a strain of dog flu that's relatively new to the U.S — canine influenza H3N2. The virus arrived from Korea last spring and has since caused flu outbreaks among dogs in 26 states throughout the nation.

No cases of human infections with the virus have ever been recorded, according to the Centers for Disease Control and Prevention. And H3N2 causes no symptoms or only mild illness in most dogs. But it is triggering some severe cases of canine pneumonia.

The night Ollie got so sick, Estes spent the night on the floor of her steam shower with the dog, and rushed him to a veterinarian as soon as she could the next morning.

"They said, 'When you get to the front of the building, call us because you can't bring the dog in through the lobby. You have to come in through the back door. It's that contagious,' " she says. "So I realized at that point: 'Wait a minute. This is something a little bit more serious than I thought it was.' "

The vet rushed the dog into intensive care. "I was petrified we were going to lose him, and pretty upset," Estes says.

After four days of intravenous fluids, help breathing and antibiotics to prevent complications, Ollie recovered. "He's perfectly fine now. But it was a scary and expensive endeavor — but mostly scary," she says.

Two different strains of dog flu are known to be circulating in the United States; canine influenza H3N2 is believed to have first arrived about a year ago, where it triggered an outbreak of illness among pets in Chicago. The virus apparently was brought into the country through O'Hare International Airport by an infected dog from South Korea.

"Dogs, like people, move all around the world." says Joseph Kinnarney, president of the American Veterinary Medical Association.

H3N2 has since spread to probably thousands of dogs in a number of areas throughout the U.S, Kinnarney says. Most have no symptoms. There have been reports of cats also getting sick from the infection in Korea, but so far that hasn't been reported in the United States.

The virus seems to be spreading much more easily than H3N8, a canine flu strain that has been in the U.S. longer. One reason is that dogs infected with H3N2 remain contagious for about three weeks, even if they have no symptoms; that's about a week longer than usual. Also, Kinnarney says, because the strain is new to the continent, U.S. dogs lack immunity to it.

Mild symptoms of the illness include a cough, loss of appetite and fatigue — these dogs recover on their own. Symptoms of severe illness — more likely in very old or very young dogs, or in dogs with other health problems — include high fevers, breathing problems and complications such as pneumonia.

Dogs that spend time around other dogs are the most likely to catch it, Kinnarney says, so pets that spend most of their time at home and rarely interact with other dogs are at low risk. He recommends that dogs that frequently come in contact with other dogs get immunized — two vaccines against H3N2 became available late last fall.

"If your dog goes to doggy day care, if your dog goes to a dog park, if your dog is traveling with you, you should get the vaccine," he says. "It's just not worth the risk."

The American Veterinary Medical Association gets funding for its educational meetings from companies that make the vaccines, but no specific products are promoted at those meetings, an association spokesperson says.

Other virologists and veterinarians say many dogs probably don't need the vaccine, especially animals that live where the virus is not circulating widely. You can check with your vet to see if there have been outbreaks in your area.

"You shouldn't be any more worried [about this strain of dog flu] than any other upper respiratory infection," says Ashley Gallagher, a veterinarian at the Friendship Heights Animal Hospital in Washington, D.C. "It's essentially just another kennel-cough disease."

Though there's no evidence so far that people can catch the virus from the dogs, there's always a chance the virus could mutate and become even more of a threat to dogs, says Edward Dubovi, a veterinary virologist at Cornell University who is tracking the virus. Like any flu virus, "it keeps changing," Dubovi says.

Copyright 2016 NPR. To see more, visit NPR.
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The Doctor's Computer Will Email You Now

NPR Health Blog - Fri, 01/29/2016 - 12:39pm

After knee surgery, David Larson, 66, of Huntington Beach, Calif., experienced pain in a calf muscle. His answer to an automated email from the doctor led to the diagnosis and treatment of a potentially dangerous blood clot.

Heidi de Marco/Kaiser Health News

A health care startup made a wild pitch to Cara Waller, CEO of the Newport Orthopedic Institute. The company said it could get patients more engaged with their care by automating physician empathy.

It "almost made me nauseous," she said. How can you automate something as deeply personal as empathy?

But Waller needed help. Her physicians in Orange County, Calif., perform as many as 500 surgeries a year, managing large numbers of patients at various stages of treatment and recovery. The doctors needed a better way to communicate with patients and track their progress.

The California startup, HealthLoop, told Waller its messaging technology would improve patient satisfaction and help keep them out of the hospital. High satisfaction scores and low readmission rates mean higher reimbursements from Medicare. Waller was intrigued and decided to give the technology a try.

So far, she's been surprised at patients' enthusiasm for the personalized — but automated — daily emails they receive from their doctors.

"There's a limited number of resources in health care. If you do 500 joint replacements in a year, how do you follow up all of those patients every day?" Waller said. The technology "allows you to direct your energy to people who need the hand-holding."

Though it may sound like an oxymoron, "automating empathy" is becoming a catchphrase in health care. The goal is to help doctors stay in touch with patients cheaply and with minimal effort.

Automated empathy is a powerful draw for hospitals and other health care providers scrambling to adjust to sweeping changes in how they're paid.

When empathy is automated, it looks like this.


Whether the emails actually trigger an empathetic connection or not, the idea of tailoring regular electronic communications to patients counts as an innovation in health care — one that has the potential to save money and improve quality.

Companies like HealthLoop are promising that their technologies will help patients stick to treatment and recovery regimens, avoid repeat hospital stays and be more satisfied with their care. Similar companies that aim to improve patient engagement include Wellframe, Curaspan and Infield Health.

HealthLoop's technology is being tested at medical centers that include the Cleveland Clinic, Kaiser Permanente-Southern California and the University of California, San Francisco.

How does it work? Doctors can send daily emails with information timed to milestones in surgery prep and recovery. The emails can ask patients or caregivers for feedback on specific issues that come up during recovery.

The doctors may write their own email scripts, as Newport Orthopedics' physicians did, or use the company's suggestions. An online dashboard helps doctors and administrators keep track of which patients are doing well and who might need more follow-up care.

A patient might see this message: "How are you? Let me know so I can make sure you're OK. I have four questions for you today." The answers to those questions can trigger a call from the doctor's office.

One of those calls may have been a lifesaver for David Larson, a Huntington Beach retiree. After Larson responded "yes" to an email that asked if he had calf pain after knee surgery, he got a call from his doctor's office telling him to come in immediately. An ultrasound confirmed he had a blood clot that could have landed him in the hospital — or worse. With treatment, the blood clot dissolved.

"There were times when it was like, 'Oh brother, they're contacting me again,' but none of this would have been caught if it wasn't for the email," said Larson, 66. "So it was more than worth it to me. Now I'm back to walking the dog, surfing, riding a bike."

How to keep patients like Larson from being readmitted to the hospital because of avoidable complications after a hospital stay has long been a vexing and expensive challenge.

Almost 1 in 5 Medicare patients discharged from a hospital — approximately 2.6 million seniors a year — must be readmitted within 30 days, at an annual cost of more than $26 billion, according to the Centers for Medicare and Medicaid Services.

For decades, hospitals had no financial incentive to keep patients out of the hospital after they were discharged. But under the Affordable Care Act, penalties were established for hospitals with readmission rates higher than the national average for certain conditions.

Also under the ACA, hospitals are financially rewarded for high scores on patient satisfaction scores and good performance on other quality measures.

The sea change is affecting doctors' groups, either because they are part-owners in hospitals, as Newport Orthopedics is with Hoag Hospital in Newport Beach, Calif., or because they participate in risk-sharing financial partnerships with them.

With money on the line, hospitals and other health care providers may be willing to pay for programs like HealthLoop, if the tryouts prove successful. And you could see your own relationship with your physician change as a result, whether you're on Medicare or not: HealthLoop is aimed at all patients, whatever the payment source.

Some experts worry that health care providers will come to rely too heavily on electronic communication as a cheap substitute for the hard work of improving the doctor-patient relationship and the quality of care that patients get.

"Automating personalized messages isn't a terrible thing; we all get some of that in our everyday lives," said Michael Millenson, a health industry consultant. "The real question is whether this kind of automated messaging is in conjunction with a cultural change in how doctors think about their patients or not."

Health care providers have experimented, with varying success, with ways to prevent complications that can lead to readmissions, said Kristin Carman, vice president of health policy research at the American Institutes for Research.

Robocalls reminding you to take your medicine, for example, don't seem to be very effective. And the new technologies don't always address demographic, cultural and language barriers that can prevent patients from communicating with their doctors. For now, HealthLoop is available in English only.

Dr. Jordan Shlain, a San Francisco internist, said he founded HealthLoop because he wanted a simple way to keep track of his patients' progress after a hospital visit or procedure.

"Every human has the same kind of trajectory of concerns and anxieties with regard to medical situations," Shlain said. "You know your doctor can't email you every day; you know your doctor usually will not call you. Now you're in a world where your doctor says I'd like to use this system to stay in touch with you and guide you through your recovery."

Dr. Thomas Vail, professor and chairman of the department of orthopedic surgery at the University of California, San Francisco would agree — up to a point.

With his UCSF colleagues, Vail is testing HealthLoop's system with his patients, and the university will be evaluating whether patients who use it experience fewer problems.

UCSF helped create some of the language for the automated emails and has a financial relationship with the company, said Dr. Aenor Sawyer, who directs UCSF's Skeletal Health Service and is a leader at the university's Center for Digital Health Innovation.

While Vail thinks HealthLoop is potentially promising, he's cautious about its role in his practice. "I don't think it substitutes for face-to-face communication," Vail said, "but it does help us collectively to not overlook something that might be important."

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California HealthCare Foundation.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Still Uninsured? Buy A Health Plan This Week To Avoid A Tax Penalty

NPR Health Blog - Thu, 01/28/2016 - 4:00pm

The price of getting a health insurance card may seem expensive, but officials say the minimum tax penalty for remaining uninsured is $695, and could rise to more than $10,000 for wealthy families who choose not to get coverage.

Photo Alto/Getty Images

Federal health officials have this message for people who want health insurance: Don't wait.

There are just four days left to sign up for an insurance plan under the Affordable Care Act, and officials from the Department of Health and Human Services are stressing that they won't extend the enrollment period this year beyond Jan. 31.

"If people plan to get covered and they want coverage this year, now's the time to do it," says Andy Slavitt, acting administrator of HHS's Center for Medicare and Medicaid Services, which oversees, the federal health insurance exchange.

Slavitt warned that people who are eligible and don't buy insurance face big tax penalties. The minimum fine for remaining uninsured is $695, and could rise to more than $10,000 for wealthy families who choose not to get coverage.

Slavitt could have been aiming his warnings at people who responded to a Kaiser Family Foundation poll released Jan. 28. The poll found that many people who don't have insurance are planning to buy a policy "in the next few months."

That's not an option for most people if they want insurance before January of next year. Officials say that after Sunday, consumers will only be allowed to buy insurance through the federal and state exchanges if they experience certain life-changing events, such as getting married or losing a job.

The CMS says about 8.9 million people have signed up so far this year for new coverage under Obamacare, or have re-enrolled in their old health plan. That brings the total number of people covered under ACA plans to 11.6 million.

The agency expects a rush of sign-ups as the deadline approaches.

Kevin Counihan, CEO of, says 11 people are signing up every second, and the website has 50 percent more traffic than it did a week ago.

Still, the Kaiser Family Foundation estimates that about 30 million people remain uninsured; many of them will be much harder to reach than those who bought insurance during the first two years after the Affordable Care Act went into effect.

The Kaiser poll shows only 15 percent of the uninsured know the deadline is Jan. 31. And while many know they face a fine if they don't buy insurance, almost none of those surveyed are aware of the size of that penalty.

Kaiser surveyed by telephone between Jan. 13 and Jan. 19 about 1,200 adults living in the U.S. The poll has a margin of error of plus or minus 3 percentage points.

More than half of those polled by Kaiser say they have never been contacted about signing up for coverage, nor have they tried to determine if they are eligible for Medicaid or subsidies to offset the cost of insurance.

Counihan says boosted its advertising in recent weeks with special television-ad purchases in eight cities that have high rates of uninsured people. He also says the agency is trying new forms of outreach, such as a partnership with the ride-hailing service Lyft to remind its drivers to shop for a health plan.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

California Pays Insurers Millions More For Hepatitis C Drugs

NPR Health Blog - Thu, 01/28/2016 - 3:09pm

Gilead Sciences' new drug Sovaldi effectively cures hepatitis C, but the price is straining state budgets.

Eric Risberg/AP

Private health plans invoiced the state of California $387.5 million to cover high-cost hepatitis C treatments in Medi-Cal between July 2014 and November 2015, when just 3,624 patients received the treatments, according to the California Department of Health Care Services.

The state's supplemental payments started after managed care plans that cover health services for almost 80 percent of Medi-Cal recipients raised "alarm" about the high cost of the new drugs. The hepatitis C treatments were eating into financial reserves, said Charles Bacchi, president of the California Association of Health Plans, an industry trade group.

"Dollars that were intended for a wide array of medical services started being gobbled up by just one drug," Bacchi said.

The health insurance companies are usually paid a flat rate per member to cover all health care needs. The Department of Health Care Services says this is the first time the state has paid health plans extra money to cover high-cost drugs. Sovaldi, a hepatitis C drug retailing at $1,000 per pill, has sent treatment prices soaring. The drug is made by Gilead Sciences of Foster City, Calif.

A mix of federal and state dollars paid health plans an average of nearly $107,000 per patient over 16 months. The spending covered the cost of Sovaldi and Harvoni, another new and expensive drug, as well as other drugs involved with hepatitis C treatment.

The funding will continue next year: The state health care agency has budgeted $303.4 million in supplemental drug payments for health plans for 2016–17.

Although the members of Bacchi's trade group benefit from the additional funding stream, he says the state's supplemental payments aren't a "sustainable" solution.

The state receives some money back from drugmakers in the form of rebates. The ultimate price paid for drugs is confidential, according to the state health agency.

A ballot initiative aimed at limiting the cost of pharmaceuticals is expected to go before voters this November. The measure would limit the amount the state pays for a drug to no more than the lowest price paid for the same drug by the Department of Veterans Affairs.

The state health care agency says its payments to insurers of Medi-Cal patients for hepatitis C drugs are a "very unique" solution, one that they may use for other high-cost drugs in the future. The state says the current hepatitis C payments may be reassessed in a year or two as the price of the drugs goes down.

"As the prescribing of the drugs levels off, as the population and the overall nature of who's getting it settles down, we may get to a point where we look at carving that responsibility back into the plans' ... rate," said Jennifer Kent, director of the California Department of Health Care Services.

But California's spending on hepatitis C drugs doesn't end there.

Another 2.7 million people on Medi-Cal have care directly reimbursed by the state. California paid almost $22 million to treat 280 hepatitis C patients in that population with Sovaldi in 2014, and more than $2.8 million for 57 prescriptions for Harvoni, according to a report from the U.S. Senate Finance Committee.

About 237,000 people in Medi-Cal are infected with hepatitis C. That means less than 2 percent of that population has received the new hepatitis C treatments in Medi-Cal as a whole, with the sum of money and during the two different time periods we reference above.

"In order for taxpayers of the state of California to afford to provide people the necessary treatments," says Bacchi, "we have to have drug pricing society can afford to pay."

If you are a hepatitis C patient or other chronic disease patient who is having difficulty getting drugs, please comment on our Medium post, tweet us or reach out through

Pauline Bartolone is a reporter for CALmatters, a nonprofit journalism venture dedicated to explaining state policies and politics.

Copyright 2016 NPR. To see more, visit NPR.
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U.S. Health Agencies Intensify Fight Against Zika Virus

NPR Health Blog - Thu, 01/28/2016 - 1:58pm
Nelson Almeida/AFP/Getty Images

A human study of Zika virus vaccine could begin as early as this year, U.S. health officials told reporters Thursday.

But the officials cautioned that it could be years before the vaccine is available for wide use.

The news came as the Zika virus continues to spread through the Americas. Still, a large outbreak is seen as unlikely in the U.S.

"There's still a lot we don't know, so we have to be very careful about making any absolute predictions," says Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases. In a briefing for reporters, he added that "we still feel it's unlikely ... we'll see wide-scale outbreaks."

That's because the U.S. has seen only limited spread of two similar viruses, dengue and chikungunya, which are also carried by mosquitoes. They have spread widely in nearby countries but mostly appear sporadically in the U.S., mainly when travelers get them abroad and return home.

Nevertheless, the National Institutes of Health and the Centers for Disease Control and Prevention are launching an intense effort to combat Zika, officials said.

The CDC is now requiring all states to report any travelers who bring the virus into the country, says Dr. Anne Schuchat, the agency's principal deputy director.

So far, 31 such cases have been reported in 11 states and the District of Columbia. None of these people is known to have spread the virus.

But 19 cases of the virus have been confirmed in Puerto Rico, Schuchat says, and some of those people had not traveled to countries that have Zika outbreaks. One case has also been confirmed in the U.S. Virgin Islands.

Schuchat acknowledged that "it's possible — even likely — we will see limited Zika transmission in the United States," but she agrees with Fauci that large-scale outbreaks are unlikely in the U.S.

The main reason is that the mosquitoes that spread the virus are primarily found only in Southern states, and the U.S. does a much better job of protecting people from mosquitoes than do other countries, Schuchat said.

That said, the agency would "remain vigilant" for any sustained transmission. "This is a rapidly changing situation," she said.

So CDC is collaborating with the NIH to develop better tests for the virus. The NIH has also issued a call for researchers already receiving funding for work on viruses like Zika to do more research to better understand it.

Work is also underway to try to develop treatments, and the NIH is pursuing two possible strategies for developing a vaccine, Fauci said.

One involves creating a vaccine from a live, but harmless form of the virus. The other, which is probably more promising, involves using DNA from the virus to formulate a vaccine, he said.

That approach produced encouraging early results in the creation of a vaccine against the West Nile virus, Fauci said.

He predicted the work could create a vaccine that might be ready for early testing sometime this year. But, he added, "we will not have a vaccine this year or probably in the next few years."

Nevertheless, the NIH has already started talking with drug companies to help develop a vaccine. "Things are moving rapidly," Fauci said.

At the same time, the Food and Drug Administration has started taking steps to protect the blood supply against the virus, CDC's Schuchat said. The virus seems to remain in the bloodstream "very briefly," she said, perhaps for only about a week.

"FDA is diligently working with its federal partners and with stakeholders, including blood collection establishments and industry organizations, to rapidly implement appropriate donor deferral measures for travelers who have visited affected regions in order to protect the blood supply," FDA spokeswoman Tara Goodin said in an email.

"FDA will also put in place recommendations to help maintain a safe blood supply in United States territories where the virus is present," Goodin wrote. "We cannot speculate on specific implementation timing at this point."

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A Few Doctors Account For Outsize Share Of Malpractice Claims

NPR Health Blog - Thu, 01/28/2016 - 10:59am

General surgeons are among the doctors most likely to be the subjects of paid malpractice claims.

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Just 1 percent of doctors are linked to nearly one-third of all paid malpractice claims, an analysis by researchers at Stanford finds. And the physicians who account for an outsize share of the claims have a set of distinctive characteristics.

The researchers said that the claim-prone physicians were disproportionately male (82 percent) and were older, rather than younger. More than half the claims were by doctors in four areas: internal medicine, obstetrics and gynecology, general surgery and general practice/family medicine.

But the biggest predictor of all for claim-prone doctors was whether they'd had a prior claim.

"Compared to physicians with only one previous claim," Studdert said, "a physician who has had three previous claims is three times as likely to have another one," said lead author David Studdert, a professor of medicine and law at Stanford. "A physician who has had four is four times more likely and so on."

In the study, published in the latest issue of the New England Journal of Medicine, researchers looked at more than 66,000 malpractice claims paid against 54,000 physicians nationwide between 2005 and 2014.

The researchers focused on paid, rather than unpaid, claims, because those are markers for substandard care. About 1 in 3 malpractice claims is ultimately paid. In the claims the researchers reviewed, one-third resulted in patient death and another 54 percent in serious injury.

The study noted that only 6 percent of doctors had any paid claims over the 10-year period studied.

In the study the researchers are clear that they have identified risk factors but that it's up to health care systems, hospital and malpractice insurers to identify and work with these doctors. "This problem of physicians who accumulate multiple claims and continue to practice ... is a significant policy problem and one that we need to address," Studert said.

But he and his colleagues noted that few of these organizations do. "With notable exceptions," the researchers write, "fewer still systematically identify and intervene with practitioners who are at high risk for future claims."

The authors of the paper call for further investigation into predicting which doctors are at risk and then implementing interventions such as training and supervision to improve their quality of care.

In California, patients can look up their doctor on the state's medical board website. Depending on the type of malpractice settlement, it will be part of the public record if the doctor has had either three or four settlements within a five-year period. Other information is also available, including whether your doctor has had a felony conviction or is on probation. Patients can use the website simply to determine that a doctor's license is valid.

But advocates like Lisa McGiffert, with Consumers Union's Safe Patient Project, say that's not enough. They have been pushing the Medical Board of California to require that doctors placed on probation notify their patients. The board has resisted taking this step.

While probation and multiple malpractice claims are not necessarily linked, McGiffert says she hopes doctors will pay attention to this study. "I have this sense that doctors as a group protect other doctors who are on probation or get in trouble because they think it might happen to them," she said. But since this study demonstrates that a small percentage of doctors are responsible for a disproportionate number of claims, it should be reassuring to physicians.

"This study is one more piece of information that regulators can use in determining their strategy in addressing the small percentage of doctors who have problems in their treatment of patients," McGiffert said.

A version of this story first appeared on KQED's State of Health blog.

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Would You Tell The World You Have Schizophrenia On YouTube?

NPR Health Blog - Wed, 01/27/2016 - 2:05pm

Rachel Star Withers says that video blogging about schizophrenia and depression has helped her manage the disorders.

Courtesy of Rachel Star

When she was 22, Rachel Star Withers uploaded a video to YouTube called "Normal: Living With Schizophrenia." It starts with her striding across her family's property in Fort Mill, S.C. She looks across the rolling grounds, unsmiling. Her eyes are narrow and grim.

She sits down in front of a deserted white cottage and starts sharing. "I see monsters. I see myself chopped up and bloody a lot. Sometimes I'll be walking, and the whole room will just tilt. Like this," she grasps the camera and jerks the frame crooked. She surfaces a fleeting grin. "Try and imagine walking."

She becomes serious again. "I'm making this because I don't want you to feel alone, whether you're struggling with any kind of mental illness or just struggling."

At the time, 2008, there were very few people who had done anything like this online. "As I got diagnosed [with schizophrenia], I started researching everything. The only stuff I could find was like every horror movie," she says. "I felt so alone for years."

She decided that schizophrenia was really not that scary. "I want people to find me and see a real person." Over the past eight years, she has made 53 videos documenting her journey with schizophrenia and depression, and her therapy. And she is not the only one. There are hundreds of videos online of people publicly sharing their experiences with mental illness.

In her early videos, Withers glowers. She tried to give off an aura of toughness befitting the daughter of a Hell's Angel biker. But there's also a sense that terror is a deep undercurrent in her life. "All right, let's go," she says in the video "Watch If You Forget," where she documents getting electroconvulsive therapy for depression. Then, in the next few seconds, "I'm about to start the electroshock therapy and, yeah, I'm pretty nervous."


Things have changed a lot since then. Now, almost all her videos open with Withers flicking her black curls, arms raised with swagger: "Hey, what's up! I'm Rachel Star!"

That public sharing of mental illness might be making a huge impact on the way our society views these disorders, especially for those of us who are digital natives. Millennials tend to be more comfortable talking about mental health issues, according to a poll released Jan. 14 by the Anxiety and Depression Association of America, along with two national suicide prevention foundations.

When it came to seeing a mental health professional, for instance, 48 percent of survey respondents between the ages of 18 and 34 said that it was a sign of strength. About 35 percent of all prior generations felt the same way.

"Our young people are accepting that mental health problems exist, and they want help for it, and they are not looking at these things as something to be ashamed of," says Anne Marie Albano, a clinical psychologist at Columbia University who is on the board for the ADAA.

She thinks that social media and videos like Withers' have helped lower stigma around mental illnesses. "Young people take advantage of this," Albano says. "It gives the opportunity for people to tell their stories and post images. This allows them to feel more hope than prior generations."

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There might be other reasons young people are less concerned about stigma surrounding mental illness. Perhaps as you age, your outlook becomes more pessimistic, says John Naslund, a Ph.D. candidate at the Dartmouth Institute for Health Policy and Clinical Practice who studies social media and mental health. He notes that the ADAA poll found that a higher percentage of older adults than young people didn't believe that something like suicide could be prevented. "Maybe they've been through this before and have had people close to them take their own lives."

He hopes things really are getting better. "It's very possible. That would be a very exciting change in the way society views mental illness," Naslund says. But the problem has not been solved. Even if information moves quickly, change is slow. "It's really important to acknowledge that people who have a serious mental disorder still face a lot of stigma," he says.

This being a Christian place, they decided I was possessed by demons.

When she was younger, Withers struggled with a lot of shame and humiliation over her disorders. "For so many years, I felt like a freak," she says. Part of that was the religious community she had joined. "Think militant Christian. Like a militaristic type," she says. When she was 17, she graduated from high school early to attend the former Teen Mania Ministries Honor Academy in Dallas. "I honestly thought that's what God wanted me to do."

At the same time, her mental condition was deteriorating. She says her schizophrenia was starting to emerge and transform into something unmanageable. The counselor at Honor Academy diagnosed her with depression and prescribed pills. They didn't help. Eventually she told them about her hallucinations. "This being a Christian place, they decided I was possessed by demons."

For three days, Withers fasted. Each morning, she met three of the school's spiritual advisers, and they spent the day performing an exorcism in a closed room. They read Bible verses, and Withers confessed to everything she could think of that might be construed as a sin — even watching demon-related TV shows like Buffy The Vampire Slayer.

At the end of the crucible, Withers was on the floor, exhausted. "I was young and here are these people who, you know, I'm told are close to God. I was like ... OK. It must be right," she says. "Surprise! It didn't work. I spent six more months there as an outcast."

Reducing this kind of stigma is a fundamental reason Withers continues making videos. She wants others to see those struggling with mental disorders with more compassion, and she wants people with a mental diagnosis to see themselves more positively.


After she posted her first video, Withers says, "People just come out of the woodwork emailing me, messaging me. The friends I've had the longest time, even people I've never met in real life with schizophrenia and like disorders. We just started talking." She got invited to mental health forums and to mental health support groups on Facebook.

"Thank you for these videos. They really help me to better understand my sister," YouTube user Kathryn Hatzenbuhler posted under one video.

Whenever I'm posting on twitter, I'll put #schizophrenia and #schizophrenic.

These online communities are an important part of Withers' life now. "Whenever I'm posting on Twitter, I'll put #schizophrenia and #schizophrenic. I'm hoping to find other people who are having problems," she says.

Withers ended up making a coloring book for kids with schizophrenia, and she shares ways she has figured out to deal with her visions and voices.

Via webcam, she showed me two askew mirrors in her room that can be angled away from the viewer. "People with mental disorders don't do well with mirrors. I just start hallucinating," she says. "It's real hard putting on makeup, you have to imagine. Having the mirrors at an angle helps."

In one video, she talks about walking up to one of her hallucinations to touch it, and that alone took away some of the fear. "It's kind of something to help you get used to your hallucinations, so you know how to respond, because the voices are always horrible. The voices are never like, 'Oh my God, you look so good today.' "


There's no hiding her disorder from anybody on Facebook, so people she knew in real life started finding out. It caused her pain at some jobs ("This one girl was like, 'Oh she's crazy. I'm not working with her.' "), but it also led some people to talk about their own or their family's experiences with mental disorder. "They'll be like, 'So ... I saw your post, Rachel. I had a question.' "

Researchers think there's a potential gold mine of mental health benefits in exchanging messages and encouragement online like this. "Social support is always the No. 1 variable that predicts a better prognosis and better care management of anyone's illness," Albano says.

It's a small leap from there to think that participating in mental health-focused communities on YouTube and Facebook might actually be making people healthier and preventing suicides. "That's probably absolutely correct," says Patrick Corrigan, a professor of psychology at the Illinois Institute of Technology. But scientists are only just now beginning to measure the effect social media might have on clinical outcomes. "It's quite a new area of thinking, online peer-to-peer support for mental illness," Naslund says.

But there's an obvious downside to being public on social media about mental health problems. "Say I have a network of friends and I have a breakdown one day. It will spread through social media, maybe in negative ways," says Michael Lindsey, a professor of social work at New York University. That could be through someone's real social groups, like at work or school, or it could be anonymous, via Internet trolls. For those already depressed, anxious or paranoid, cruel comments and messages could have a terrible impact.

You're able to pull yourself out in a way to help someone else.

But in Naslund's research, he says that problems with online attacks have been extraordinarily rare. "If someone did post a derogatory comment, seemed a little harmful, other people would come to the defense and say, 'Don't listen to that,' " he says. "[Social media are] way more supportive than we imagined."

According to Naslund, the benefits seem to vastly outweigh the harms. "That's clear in the literature," he says.

And Withers agrees. She doesn't think that people with mental health problems usually go on social media and spiral out of control even more. "I'm sure it happens somewhere on some area of the Internet," she says. "But I think usually when I'm feeling depressed and stuff, but then I see someone else thinking of hurting themselves, the opposite kicks in. It's like, no. You have so much to live for. You're able to pull yourself out in a way to help someone else."

When Withers does get trolls, she blocks them. "Anything remotely violent towards me gets blocked," she says. "Like — I'm not going to respond to that. Don't call me that word."

Still, she cautions others to think carefully before coming out to the world about their mental illness. It can be dangerous, she admits. She says she gets phone stalkers and death threats. But she is still glad that she did it. It's uncomfortable for her to think what might have happened if she never went online about her depression and schizophrenia. "I see myself being a lot more closed off," she says. "I hope I would have found other people's videos."

Withers attributes a lot of her transformation to electroconvulsive therapy. She says it knocked out a lot of her deep depression. And Withers thinks sharing on the Internet has also helped. "It helps me to vocalize it and put it all out there," she says, and it makes her feel like she is less "broken and sick" when other users empathize with her online.

Rachel Star YouTube

Recently, she posted a video to YouTube called "There Will Be Beautiful Days." It's short, reaching just past a minute long. Withers smiles and says she knows things are hard now. Maybe harder than they've ever been. But it's going to be OK. And at some point, you'll have some good days. Maybe even just one great day, but it'll be enough. It will make life worth fighting for.

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Teaching Parenting Skills At Doctor Visits Helps Children's Behavior

NPR Health Blog - Wed, 01/27/2016 - 12:50pm

As researchers have come to understand how poverty and its stresses influence children's brain development, they've begun untangling how that can lead to increased behavior problems and learning difficulties for disadvantaged kids.

Rather than trying to treat those problems, NYU child development specialists Adriana Weisleder and Alan Mendelsohn want to head them off.

They say they've found a way: Working with low-income parents when they bring babies and young children to the pediatrician. They've been able to reduce key obstacles to learning like hyperactivity and difficulty paying attention, according to research published Wednesday in the journal Pediatrics.

The researchers recruited mothers with newborns to participate in the study and divided them into three groups. One group received standard pediatric care, which includes some basic coaching on reading to kids. The second went home with books, toys and informational pamphlets, and the third worked with a trained child development professional for about 30 minutes before or after each checkup. The specialist filmed each mother and child reading or playing together for a few minutes, talked to the mother about the positive things she did with her child and sent her home with the video.

At 3 years old, 50 percent fewer children in the video interaction group who were most at risk showed signs of hyperactivity compared with those who got standard pediatric care. The results were positive, though less remarkable, for the video group as a whole.

Improving a child's ability to focus, regulate behavior and cooperate with other kids can help a child learn. "If [children are] controlling their behavior, not overreacting and paying attention, they will be taking in more information from learning activities," says early childhood expert Susan Landry, director of the Children's Learning Institute, who wasn't involved in the study. "All those things help in the classroom to be a better student."

The results show that a relatively cheap form of intervention works, the researchers say, and could be used to reach a big swath of the population, including families who are often hard to reach because parents work multiple jobs or phones get disconnected.

By using pediatric checkups as a way to engage parents, the researchers say they could reach every child without burdening parents with additional transportation or logistical demands. "We're leveraging the relationship they already have with the pediatric clinic," Weisleder says.

While home visits to provide this sort of one-on-one behavioral training can cost between $1,500 and $10,000 per child per year (models vary widely), the video program costs around $200. David Willis, director of the federal Health Resources and Services Administration's Early Childhood Home Visiting Program, notes that the home visit program is far more intensive than the NYU video method, with families getting between 25 and 30 visits per year. Each lasts at least an hour.

"The families we serve are some of the most challenged families in the country," Willis says. Home visits are an important resource for them, but he estimates the program reaches only 1 to 3 percent of families who could benefit from it. "To simultaneously have this [video interaction] program that's likewise focused on promoting positive parenting and brain development in the youngest families is really significant," he says.

Landry thinks the video intervention could be embedded into almost any type of pediatric setting for very little cost. "That's something all of us have been searching for, "she says. Her team at the University of Texas Health Science Center at Houston is working to make home visits by child development specialists more affordable by giving parents iPads so they can work remotely with experts.

The findings don't just apply to disadvantaged families. As a pediatrician, the first advice Mendelsohn gives families when kids have behavior problems is to think not about discipline but rather positive steps.

"Can you start to pay attention to your child when your child is being good?" he asks. Negative interactions can turn into a cascade, he says, in which parents feel worse about themselves, which influences kids negatively, which ultimately makes things even harder for parents. "Kids misbehave because it's their job," he says. "It's our job to be able to help them learn and regulate their behavior."

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Do-It-Yourselfers Face Penalties Over Their Cut-Rate Health Insurance

NPR Health Blog - Wed, 01/27/2016 - 11:46am

Last fall, Shalonda Brown decided she'd had it with paying nearly $1,000 a month for family health, dental and vision plans through her job at an independent lab in Dallas.

Casting about for an alternative, she checked out individual family plans on No dice. The family's income was too high to qualify for subsidies and comparable coverage wouldn't be any cheaper.

So Brown instead cobbled together three different policies that each provide limited coverage for her, her husband and 2-year-old daughter: a short-term plan with a $10,000 deductible that provides up to $1 million in coverage for just under a year; a critical illness plan that pays a $20,000 lump sum if one of them is diagnosed with invasive cancer, heart attack or stroke; and a dental plan that provides $1,000 in coverage. The total monthly tab: $390.

"I feel like it's just giving me everything I need as of right now," said Brown, 31. "Me and my family, knock on wood, there's nothing urgent or major to deal with now."

But there's a catch. Under the health law, most people are required to have insurance that meets minimum standards or pay a fine. Limited benefit policies such as short-term, critical illness, accident, dental and vision plans don't qualify.

In 2016, the penalty is $695 per adult and $347.50 per child, or 2.5 percent of household income, whichever is greater.

Brown knows she'll face a penalty if her family doesn't have comprehensive coverage this year, but she's willing to pay the fine. "When I look at what I'm saving having a short- term plan versus regular insurance, it'll balance out," she said.

Faced with sky-high premiums and high deductibles for traditional plans, it's not surprising that some people are looking at other options.

"They may be making the best decision they can for themselves given their financial and health situation," said Sabrina Corlette, research professor at Georgetown University's Center on Health Insurance Reforms. "But it's a roll of the dice, and if something bad happens, they could find themselves on the hook for a very big bill."

Under the health law, regular health plans are prohibited from imposing lifetime or annual limits on coverage, or from turning people down because they're sick. Short-term policies — which generally impose dollar limits on coverage, don't cover treatment for preexisting conditions and may refuse to renew a policy if someone gets sick — don't meet those standards.

But many people are taking an interest in the plans nevertheless. In 2014, when the provisions of the health law took effect, the number of people applying for short-term plans rose 130 percent, to 147,383, at online health insurance vendor eHealth.

Sales of critical illness and accident policies, which generally pay a lump sum if someone has a qualifying event such as a car accident or cancer diagnosis, are also on the rise. Sales of critical illness policies on the individual market grew to $311 million in 2014, a 24 percent increase over five years, according to financial services research company LIMRA. Nongroup accident policy sales reached $430 million in 2014, a 13 percent rise over five years.

As consumer interest in limited benefit plans has grown, some carriers are bundling critical illness and accident insurance policies together, or offering a single plan that provides coverage for both, says Nate Purpura, vice president of consumer affairs at eHealth.

The typical purchaser of accident or critical illness coverage at eHealth is a self-employed person who already has a comprehensive insurance plan and wants some extra financial protection, says Purpura. It's less common for people to cobble together different limited plans to rely on as a replacement for regular insurance.

"Short-term insurance is designed for a short-term gap, and accident and critical illness plans are not designed to replace major medical," Purpura said.

With an average lump sum payout of $31,000 for an individual market critical illness plan, according to insurer Gen Re, the policies won't come close to covering treatment for a serious illness.

"We just want to be sure that people understand what they're buying and understand the limitations of these plans," says Anna Howard, a policy principal at the American Cancer Society Cancer Action Network.

For her part, Shalonda Brown hopes to get regular insurance again soon. Her husband has applied for a government job with comprehensive health insurance that, she hopes, would be more affordable than her employer plan.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter:@mandrews110.

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Big Zika Virus Outbreak Unlikely In The U.S., Officials Say

NPR Health Blog - Tue, 01/26/2016 - 6:09pm
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The Aedes aegypti mosquito is one of two types thought to be capable of carrying and transmitting the Zika virus.

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The outbreak of Zika virus in Brazil and other countries has raised concern that the pathogen could start spreading widely in the United States, as well. But federal health officials and other infectious disease specialists say so far that seems unlikely.

"Based on what we know right now, we don't think that widespread transmission in the United States is likely," says Dr. Beth Bell, director of the National Center for Emerging and Zoonotic Infectious Diseases at the Centers for Disease Control and Prevention.

There are several reasons for Bell's cautious optimism that isolated cases that show up in the U.S. could be contained. The first is that the two species of mosquitoes that could be capable of transmitting the virus, Aedes aegypti and Aedes albopictus, live mostly in the southern, more tropical parts of the U.S. That makes it likely that transmission would be limited primarily to these areas. And for various reasons, the chain of events and conditions the virus needs in order to spread is more easily disrupted in the U.S. than elsewhere.

For example, many people in the U.S. have air conditioning in the summer, so aren't as likely to leave windows open at the times of day when mosquitoes are especially active. Open windows also tend to have screens. And many counties and other municipalities spray to kill mosquitoes and are vigilant in trying to eliminate pools of standing water where the insects can breed.

"These are all conditions that make it less likely for ongoing, large-scale spread to occur," Bell says.

Still, travelers who have gotten infected with the Zika virus in other countries have already arrived in the U.S. and more are expected, raising the possibility that the virus could spread a bit beyond those cases, Bell says.

"There certainly is the possibility for transmission," Bell says. And since the virus is new to the U.S., most people have no immunity to it.

But even if that occurs, Bell and the CDC predict that any outbreaks would likely be very small. That's been the case so far with two similar viruses that have spread rapidly throughout Latin America and the Caribbean in recent years: dengue and chikungunya.

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"What we saw with chikungunya, and what we've seen with dengue," Bell says, "is some small situations with localized spread in southern parts of the United States, but with very limited transmission."

Bell says she doubts Zika would fan out across the U.S. in the way that West Nile virus has spread. For one thing, West Nile is primarily transmitted by a different type of mosquito — one that is found throughout the country. Also, birds can be infected with West Nile and carry it from place to place. That doesn't happen with Zika virus, which has no known bird or animal reservoir.

Dr. Anthony Fauci, who heads the National Institutes of Allergy and Infectious Disease, says he agrees that it's unlikely that the U.S. will see a widespread outbreak of Zika.

"If you look at historically what we've seen, I think we can say that it's a remote possibility and unlikely to happen," Fauci says. Nevertheless, Bell acknowledged that experts can " 'never say never,' " and Fauci agrees anything is possible.

There are still many uncertainties, including exactly what Zika is doing to pregnant women and their babies, what other complications the virus may cause and why it has suddenly taken off in parts of Brazil and elsewhere.

Those unknowns mean "there is a risk" to some people, says Dr. Albert Ko of the Yale School of Public Health, who's been studying the outbreak in Brazil. "We don't know how big that risk is. It seems low. But we know not that much about this disease at this moment."

Ko and other experts say they are rushing to learn more about the Zika virus and are on the lookout for disturbing surprises.

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How Meditation, Placebos And Virtual Reality Help Power 'Mind Over Body'

NPR Health Blog - Tue, 01/26/2016 - 1:22pm
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Science writer Jo Marchant investigated the healing power of the mind for her new book, Cure.

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While researching the book Cure, science writer Jo Marchant wanted to understand how distraction could be used to nullify pain, so she participated in a virtual reality experiment.

During the first part of the experiment, Marchant sat, without distraction, with her foot in a box of unbearably hot water. "It felt like a very intense burning pain on my foot when I just experienced it on its own," Marchant tells Fresh Air's Terry Gross.

But then Marchant put on noise-canceling headphones and began to play a snow-and-ice-themed immersive video game that had been developed specifically for burn patients. This time, when the researcher applied the same burning pain to her foot, she barely noticed it.

Jo Marchant holds a doctorate in genetics and medical microbiology and has written for New Scientist, Nature and Smithsonian.

Garry Simpson/Crown

"The researchers explained it as our brains only have a certain capacity for attention," Marchant says. "If you've got something that's really commanding your attention, there's less attention left over for experiencing the pain."

During the course of her research, Marchant also investigated the science behind the placebo effect, hypnosis, meditation, prayer and conditioning. She says that the healing power of the brain could offer a powerful complement to modern medicine. "That's a whole different approach to pain that I think tells us that drugs aren't the only answer," she says.

Interview Highlights

On harnessing the placebo effect to feel better

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A Journey into the Science of Mind Over Body

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One thing that people often don't realize about the placebo effect is there isn't just one placebo effect. There are many, depending on what we think a treatment is going to do for us. So, for example, if you take a fake painkiller, that actually reduces pain-related activity in the brain and the spinal cord and it causes the release of natural painkillers in the brain called endorphins. And these are actually the painkillers that opioid painkillers are designed to mimic, so it's working through the same biochemical pathway that a painkiller would work through. But if a patient with Parkinson's takes a placebo that they think is their Parkinson's drug, they get a flood of dopamine in the brain, which is exactly what you would see with the real drug.

Even with altitude sickness, for example, if somebody at altitude takes fake oxygen, you see a reduction in ... prostaglandins. ... These actually work to dilate blood vessels and they cause many of the symptoms of altitude sickness.

So what you see in all these different conditions is that taking a placebo, or, to be more accurate about it, our response to that placebo, can cause biological changes in the brain that actually ease our symptoms, and that's not something that's imaginary; that's something that's underpinned by these biological changes that are very similar to the biological changes you get when we take drugs.

On possible explanations for why the placebo effect sometimes works

Some of it seems to have to do with stress and anxiety — if we feel that we are in danger or under threat, the brain raises its sensitivity to symptoms like pain. ... Whereas, on the other hand, if we feel that we are safe and cared for and things are going to get better soon, we can kind of relax, we don't need to be so alert to these symptoms. So that's one thing that might be at play.

There are also physiological mechanisms for example, conditioning. ... If listeners are familiar with Pavlov's dogs, so this is the idea that a physiologist called Ivan Pavlov conditions dogs so that whenever he gave them their food he would make a noise, like ring a bell for example, and eventually they came to associate the bell with their food and they would salivate just to the sound of the bell. He didn't need the food anymore. We can all be conditioned to have different physiological responses to a stimulus like that, and that works not just for salivation, but for things like immune responses. So, for example, if you take a pill that suppresses your immune system, later on, if you take a similar looking placebo pill, even if there's no actual active drug in there, your body will mimic that same response. Your body has learned that response and that just happens automatically; it doesn't matter what you believe about the pill.

On making sense of placebo responses

I don't think we should be giving people fake pills. I think, first of all, there is some evidence that honest placebos still work, so there are studies in various conditions, for example — irritable bowel syndrome, headaches, hyperactivity disorder — where patients have received placebos but they knew they were placebos and still got a benefit from that. And that's probably all down to things like just being in a trial, the feeling that you're being helped can have those effects on the brain. So you don't necessarily have to lie to people, but beyond that, I think what we need to do is try and understand what are the active ingredients of placebo responses — whether that's expectation, which is then influenced by all different things, such as your previous experiences with treatment, what you're told about a treatment, how sympathetic your physician is. There's all sorts of things that are feeding into how you'll respond to that treatment. So I think we need to try and understand those things and think how we can incorporate those elements into medical care routinely, rather than, for example, relying on fake pills.

On how meditation and mindfulness can affect health

The basic idea [of mindful meditation] is that you try to focus on the present moment rather than worrying about the past or the future. ... There have been hundreds of studies on mindfulness now, and there's very good evidence that it reduces stress and anxiety, and that it reduces symptoms such as chronic pain and fatigue. So that's very well shown now in the analysis of lots of different studies, and that's in healthy people but also in people with depression or people with serious illness. What there's less research on is whether that feeds through into benefits for the immune system and sort of more physical health benefits, if you like.

There is some evidence suggesting that mindfulness meditation can make us more resistant to infection and that's everything from winter colds to slowing the progression of HIV and that it gives people a better response, for example, than flu vaccine. There was another study suggesting that people with psoriasis responded better to their medication when they also had mindfulness training. ... But the studies so far are quite small, so it would be great to see more research on that.

On why slow, measured breathing helps with stress

With a stress response, the brain and the body are influencing each other in both directions, so if we see a danger then that's going to make us feel stressed and one of the follow-ons from that is that our breathing is going to speed up. If you were to speed up your breathing on your own, you'd probably start to feel a bit more aroused and on edge. And, equally, if you calm the breathing down, you're kind of forcing your body into a more relaxed state and you will then experience probably fewer negative thoughts as a result. When we're stressed, our brains almost come up with negative thoughts to try and explain why we're stressed, if you like, if you're kind of anxious or worried about something, all sorts of negative thoughts are going to pop into your head, but if you can just calm that down, then that's going to have a beneficial effect on your mental state as well.

On how how stress can rewire the brain — and creates more stress

Your brain reflects the way that you think throughout your life. You kind of shape it by your thoughts and your behaviors. If you play violin for eight hours a day, then the parts of the brain responsible for helping you to play the violin will get larger. If you're thinking stressful thoughts for the whole day then those parts of the brain are going to get larger and other parts of the brain will deteriorate. It's kind of an irony because then the very brain circuits that we would need to try and counter that are no longer working as well as they should, so that's why something like meditation can be helpful because just simply saying, "Oh, I'm going to change how I think now. I'm not going to be as stressed now," doesn't really work; you have to change your brain over a long period of time.

Read an excerpt of Cure

Copyright 2016 Fresh Air. To see more, visit Fresh Air.
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Depression Screening Recommended For All Pregnant Women, New Mothers

NPR Health Blog - Tue, 01/26/2016 - 11:06am

Untreated depression can harm the health of mothers and their children.


Pregnant women and new mothers need more attention when it comes to screening for depression, according to recommendations issued Tuesday by the U.S. Preventive Services Task Force.

That came as part of the panel's recommendation that all adults should be screened, in a situation where they can be provided treatment or get a referral if they are clinically depressed.

The announcement follows similar recommendations in 2002 and 2009. What's new this time is the special shout-out for pregnant women and new moms. They need special recognition, the task force says, because of evidence showing that they can be accurately diagnosed and successfully treated, and because untreated depression harms not only the mother, but her child as well.

Depression is the leading cause of disease-related disability in women around the world. Nine percent of pregnant women and 10 percent of new moms will go through a major depressive episode, according to evidence cited by the task force. And studies have shown that babies and toddlers with depressed moms are subject to lots of problems. They may be more difficult to console, be less likely to interact or have more sleeping problems.

The independent panel's recommendations are influential — many health insurers and health systems follow their suggestions. But the announcements often come with controversy. Recent and recurring recommendations against automatic annual mammograms for women in their 40s have generated multiple headlines.

But concerns among mental health researchers who got an early glimpse of the advice about testing for depression have been mild — mostly questions about the best depression screening test to use and the importance of emphasizing more research on treatments.

There's no argument about the task force's call for recognizing the needs of pregnant women and new moms. "Historically, depression in these populations has been underrecognized and undertreated," says Evette Ludman, a clinical psychologist who studies behavioral science for Group Health Research Institute in Seattle.

Most important, she says, is the recommendation that there be access to some sort of effective care when someone is diagnosed.

Heidi Koss got no screening with the birth of her first child 20 years ago, not even an open ear when she mentioned symptoms of depression to her obstetrician at her six-week checkup. "He said 'Oh, this is typical of a lot of moms; perhaps you should get out more, maybe buy a new dress.' "

"It just added to a sense of helplessness, hopelessness and isolation," she says now. In 2011, she told NPR about several attempts to commit suicide before finally finding a sympathetic mental health counselor about a year after her first child was born.

Her experience with postpartum depression inspired Koss to get a degree in counseling. She now practices in Kirkland, Wash., and is the Washington state coordinator of a nonprofit education group, Postpartum Support International.

"Pregnancy is not from the neck down," she says, pointing to studies that show that more women suffer from mental illness during pregnancy and after pregnancy than develop gestational diabetes or pre-eclampsia, or go into preterm labor.

And she singles out a small British study done in the late 1990s that claimed that psychiatric disorders, and suicide in particular, were the leading cause of maternal death.

The task force report notes that one of the biggest challenges is treatment.

"Because hopelessness and inertia are often part and parcel of depression, it can be challenging for persons living with depression to keep at it until finding the treatment that is right for them," says Ludman of Group Health Research Institute. The task force notes that talk therapy (specifically a kind called cognitive behavioral therapy), drug therapy or a combination of medication and therapy may be necessary.

But the group backs off on recommending drug treatment for pregnant women with depression because of the possibility of problems associated with certain drugs called SSRIs. Some studies have shown a small risk of increased problems that include miscarriage and preterm birth. Instead, the suggestion for pregnant or breastfeeding women is for cognitive behavioral therapy or some form of counseling.

The task force's recommendations for pre- and post-term moms appear in the current issue of JAMA, the journal of the American Medical Association. They track with advice from other groups, including the American Academy of Family Physicians, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

Legislation introduced in Congress last July would authorize the federal government to fund screening and treatment for pregnant women or women who have given birth within the past year.

Joanne Silberner, a former health policy correspondent for NPR, is an artist in residence at the University of Washington's department of communication.

Copyright 2016 NPR. To see more, visit NPR.
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A Judge's Guidance Makes Jurors Suspicious Of Any Eyewitness

NPR Health Blog - Tue, 01/26/2016 - 5:04am
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The state of New Jersey has been trying to help jurors better assess the reliability of eyewitness testimony, but a recent study suggests that the effort may be having unintended consequences.

That's because a new set of instructions read to jurors by a judge seems to make them skeptical of all eyewitness testimony — even testimony that should be considered reasonably reliable.

Back in 2012, New Jersey's Supreme Court did something groundbreaking. It said that in cases that involve eyewitness testimony, judges must give jurors a special set of instructions. The instructions are basically a tutorial on what scientific research has learned about eyewitness testimony and the factors that can make it more dependable or less so.

"The hope with this was that jurors would then be able to tell what eyewitness testimony was trustworthy, what sort wasn't, and at the end of the day it would lead to better decisions, better court outcomes, better justice," says psychologist David Yokum.

Yokum was a graduate student at the University of Arizona, doing research on decision-making, when he and two colleagues, Athan Papailiou and Christopher Robertson, decided to test the effect of these new jury instructions, using videos of a mock trial that they showed to volunteers.

The fictional trial involved a robbery and murder at a convenience store. Actors played all the roles, including an eyewitness. And the researchers made two versions of this trial that differed only in the quality of the eyewitness testimony.

One had testimony that would be considered strong, according to the New Jersey instructions. The other had eyewitness testimony that was much more sketchy. "Imagine a best- and a worst-case scenario," explains Yokum. "We deliberately designed the video that way."

For example, police departments frequently ask eyewitnesses to identify a suspect using a photo lineup. The New Jersey instructions say it is best if the photos are shown to the witness by a police officer who doesn't know which one is the suspect.

"The concern there is that if an officer knows who is in the photo lineup, they might accidentally give some sort of hint to the person about who it is," says Yokum.

So, in their video with the strong eyewitness testimony, the officer didn't know who was who. But in the video with the weaker testimony, he did. There were other differences as well, such as the number of photos in the lineup.

After watching one of these videos, volunteer jurors either did or did not hear the long New Jersey instructions. And then the juror had to decide. Guilty as charged?

"We found that the instruction had an effect," says Yokum. People who heard about the science of eyewitness testimony were much less likely to convict the defendant.

That was true regardless of whether the eyewitness testimony was high-quality or low-quality, says Yokum, suggesting that the instructions simply made the jurors suspicious of all such testimony.

The researchers recently published their research in the journal PLOS ONE.

"Whether this is a good or bad thing relative to not having the New Jersey instruction, I think, is kind of an open question," Yokum notes.

Alan Zegas, a criminal defense attorney who handled one of the cases that led to the New Jersey instructions, thinks the finding is definitely a good thing.

"Our criminal justice system, our Constitution, has at its foundation the notion that it is better to let a thousand guilty people go free than to convict an innocent person," says Zegas.

Just look at all the people who have been identified by eyewitnesses and later exonerated through DNA testing, he says, adding that "there should be skepticism of eyewitness testimony."

It's impossible to know what the real-world effect of these instructions has been so far, Zegas says. After all, most cases involve various kinds of evidence, not just identification from an eyewitness. But for those rare cases that really do hinge on eyewitness testimony, he thinks the New Jersey instructions could make a huge difference.

Copyright 2016 NPR. To see more, visit NPR.
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Journal Editors To Researchers: Show Everyone Your Clinical Data

NPR Health Blog - Tue, 01/26/2016 - 3:59am
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Medical editors don't usually attract much attention. They perform their daily duties evaluating submissions and producing articles that, on good days, influence practice and policy.

But last Wednesday, the editors of the leading medical journals around the world made a proposal that could change medical science forever. They said that researchers would have to publicly share the data gathered in their clinical studies as a condition of publishing the results in the journals. This idea is now out for public comment.

As it stands now, medical scientists can publish their findings without ever making available the data upon which their conclusions were based.

Only some of the top journals, such as The BMJ, have tried to make data sharing a condition of publication. But authors who didn't want to comply could just go elsewhere.

Think about it. The scientists who generate the data, with the participation of the people being studied and often with public funding, control it and most often don't share. By holding the data tight, researchers who ran a study are the only ones who can conduct additional analysis and studies.

If the proposed change is adopted, as I hope it will be, it would make sharing more compelling.

Inaccessible data is a problem rife throughout medical science. Industry traditionally held its data close — but so did academics.

These researchers have felt that they deserved the right to future papers for all their hard work gathering the original data. And maybe they didn't want others examining their work.

But this practice shields data from scrutiny. It forgoes an opportunity to crowdsource knowledge from scientists who weren't associated with the original study. It also violates the sensible practice of showing your work, not just the presumed answer.

Some skeptics contend that those who pore over data generated elsewhere are nothing more than "research parasites." But that disparaging term neglects the key role that independent scientists can play in bringing new insights and also in validating the quality of the data that were collected. Access is also central to the scientific method and the idea of replication to establish the truth.

The editors who made the proposal sought to be sensitive to the rights of researchers, funders and participants. But their intent is clear: It's time to share.

The past culture has impeded science. For example, many times in my career as a heart disease researcher, I respectfully requested access to clinical trial data held by others. The response was no — regardless of the merit of the request — and most often from other academics. It is a behavior that would be hard to imagine in other fields, like physics or astronomy.

The data from clinical trials have the potential to provide additional knowledge that often goes untapped.

There were times my research group was able to gain access to data through the National Heart, Lung and Blood Institute, which promotes sharing of trials it funds, or through litigation. We uncovered insights that weren't in the original articles. Our work produced papers that found their way into the New England Journal of Medicine and JAMA, the Journal of the American Medical Association. The findings have since been cited by thousands of other papers, incorporated in treatment guidelines for doctors and patients. In several cases our results upended the original conclusions.

Others have also used trial data to replicate and extend findings from the initial studies and made critically important contributions.

In recent years the momentum for open science has grown rapidly. This action by the editors follows directly from guidance in 2015 from the National Academy of Medicine (formerly the Institute of Medicine), a body of the nation's top medical experts, that said clearly it is time for the culture of medical research to change.

Companies such as GlaxoSmithKline, Johnson & Johnson and Medtronic have led the way in sharing their trial data. Our group at the Yale Center for Outcomes Research and Evaluation started the Yale Open Data Access Project to promote data sharing and was an early advocate for open science. We are showing the feasibility of establishing partnerships with industry and acting as a trusted intermediary. Visit the site, and you can see a variety of trials from Johnson & Johnson that are available to scientists around the world.

With sharing, the sky hasn't fallen and worthwhile independent projects that could not have been done otherwise are proceeding. Many academics and companies are lagging, however. As a result, the data from a large number of trials remain off-limits.

Amid the progress, there has been a lack of consequences for not sharing. Even as the benefits from sharing are manifold, to be honest, it's easier not to share. Why expose your data to others? Why compromise your ability to publish more at your own pace? Why risk the possibility that someone could find an error? Why let others benefit from your hard work? Why spend the money to do it?

The absence of an incentive to share seems about to change. The proposal by the medical editors outlines an approach that would require: a data-sharing policy when the study is started; a commitment to share within six months of publication; and that those who use the data acknowledge those who produced it. The data should be down to the level of the individual patient (identifying information will be removed) rather than just summary data, an important detail that will allow rigorous science to proceed.

Among the first things we learn in school are to share and to show our work. This lesson has been lost on medicine for many years. The medical editors are reminding us that we scientists have a principal responsibility to society and to those who agreed to participate in our studies.

There are many details to resolve. How will sharing work? Who will pay for it? How will the researchers who produced the work get credit in the subsequent analyses? All good and difficult questions, but it is high time to find solutions.

For now, this proposal is out for public comment. It is likely that mostly scientists will weigh in on how the change would affect their work. It would be great, in my view, if the general public participated too. Do people want to see scientific data exposed to the light, available to advance knowledge for generations? The public stands to benefit the most. I hope that voices other than those of my colleagues will be heard.

Harlan Krumholz is a cardiologist and the Harold H. Hines Jr. Professor of Medicine at Yale School of Medicine. He directs the Yale-New Haven Hospital Center for Outcomes Research and Evaluation and is a co-director of the Robert Wood Johnson Foundation Clinical Scholars Program. To comment on the proposal described above, you can go to

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Insurers Hire Social Workers To Tackle The Opioid Epidemic

NPR Health Blog - Mon, 01/25/2016 - 2:02pm
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A pharmacist counts pain pills. In an effort to curb the abuse of Oxycontin, Vicodin and other opioid painkillers, some health plans in Massachusetts now limit a patient's initial prescription to a 15-day supply, and plan to halve that number in February.

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For many people struggling with opioid use, a key to success in recovery is having support. Some are getting that support from an unlikely place: their health insurer.

Amanda Jean Andrade, who lives west of Boston in a halfway house for addiction recovery, has been drug- and alcohol-free since October. It's the longest she's been off such substances in a decade. She gives a lot of the credit for that to her case manager, Will — who works for her insurance company.

"Having Will is the best thing in the world for me," Andrade says. "Because if I have the slightest issue with anything to do with my insurance that includes, like, prescriptions — even when I had a court issue — I know that I can call him."

Andrade's insurer is CeltiCare Health Plan, one of several health insurance companies in Massachusetts taking aggressive new steps to deal with the growing opioid epidemic. CeltiCare has about 50,000 members in the state, and mostly manages care for patients on Medicaid.

Insurers typically cover some inpatient substance use treatment and detox, says CeltiCare's president and CEO Jay Gonzalez, but those are only short-term solutions. After a patient is discharged, relapse — and readmission — are likely without follow-up support.

That's why CeltiCare assigns social workers to some of the people it insures.

"This is the biggest potential solution to this problem, I think, because at the end of the day we have to find the members who are or could be in trouble, and we need them to be invested in addressing their issues," Gonzalez says.

For CeltiCare, the costs related to the opioid epidemic are huge: Nearly a quarter of its hospital admissions are related to substance use, Gonzalez says. The insurer spent more than 10 percent of its budget last year on Suboxone, a medication to treat addiction to narcotics. That's more than it spent on any other drug.

Gonzalez believes that investing in the extra attention to patients like Andrade will eventually pay off, by helping them stay sober for good.

"At the end of the day, we think it's going to cost a lot less, Gonzalez says. "They're going to be healthier; they're not going to be showing up in the emergency room. We have people who show up in the emergency room 50 to 100 times a year. That's very expensive, and it's not good for the member."

CeltiCare is also training some of these members and their families in how to use Narcan, the drug that reverses an opioid overdose. And the firm is putting tighter limits on the initial prescription of opioid painkillers it permits for each patient.

Right now patients initially can be prescribed no more than a 15-day supply of the pain pills; CeltiCare plans to reduce that to a seven-day supply as of February. (Prescribing doctors will be permitted, of course, to renew the prescription as they see fit, when pain warrants it.)

CeltiCare isn't the only health insurer looking for new ways to deal with the opioid problem in Massachusetts. For the past three years, the state's largest insurance company, Blue Cross Blue Shield of Massachusetts, also has been limiting the supply of opioids it allows patients in an initial prescription.

Dr. Tony Dodek, associate chief medical officer for the company, says about 11,000 of the insurer's more than 2 million members were treated for a substance use problem in the past year. Federal numbers show that most misused controlled substances originate as legal prescriptions, so he sees limiting prescriptions as one simple and straightforward way to deal with the problem.

"We decreased the number of doses in circulation — when you compare the three-year period after implementation to the prior period — by over 21 million doses," Dodek says.

What's not so easy is finding ways to keep patients out of the hospital. Between 1993 and 2012, the rate of inpatient hospital stays related to opioid use went up 150 percent across the country, according to data from the Association of Community Affiliated Plans, a group of 60 not-for-profit health plans in two-dozen states.

In response, several of the association's members across the country are now taking steps that include screening those they insure for substance abuse, using social workers to help keep them in treatment, and improving the use of medications like Suboxone.

Neighborhood Health Plan in Boston is one of those plans. Its chief medical officer, Dr. Paul Mendis, says the insurer has developed algorithms to identify who is at risk for relapsing after drug abuse treatment, and has hired social workers to reach out to those members.

Mendis says they look for members who have a traditional medical diagnosis as well as a substance use issue.

"You actually have to, in many cases, reach out using their other medical diagnosis as the reason for the outreach," Mendis says. "If you just call somebody cold and say, 'We found you,' I don't think those calls would be well-received." The health insurer is also piloting a program in which a recovery coach is assigned to members who land in the hospital after an overdose.

For any such program to work, the person with the drug problem has to trust the insurer's recovery coach, social worker or case manager.

Andrade says she quickly came to trust her case manager, even though many other people in her life have let her down along the way. She started using drugs as a teenager, she says, after both her parents left home and she was essentially homeless. She temporarily stayed in foster care and with various family members or boyfriends — some of them abusive. Her son was born six years ago, but she lost custody and her drug use spiraled.

The case manager from CeltiCare is now working on helping her find a job and more permanent housing, she says. And he and others are holding her accountable in ways she believes will help keep her on track in her recovery.

"I have, in one of my poems," Andrade says, " 'Don't let anyone diminish your self-confidence, your pride. If you feel something, it means that you tried.' I at least want to try for all the people that tried for me."

A version of this story ran on WBUR's blog CommonHealth, where you can find more coverage of the opioid addiction crisis in Massachusetts.

Copyright 2016 WBUR. To see more, visit WBUR.
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What's Your Type? With Diabetes, It Can Be Unclear

NPR Health Blog - Mon, 01/25/2016 - 12:23pm

Just because you use insulin doesn't mean you have Type 1 diabetes.

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A drop in the number of newly-diagnosed diabetes cases is good public health news. But for the Type 1 diabetes community it's a source of frustration, because the numbers hide their story.

Last month, the Centers for Disease Control and Prevention announced that new cases of diagnosed diabetes among adults in the U.S. had finally dropped after decades of growth, from 1.7 million in 2008 to 1.4 million in 2014.

The decline in new cases gives "confidence that our diabetes prevention efforts are working and we are moving in the right direction," CDC officials said via email to Shots. "We know that long-term lifestyle changes in those at high risk are critical to prevent Type 2 diabetes and maintain this progress."

While it's certainly the right direction for the more common Type 2 diabetes, the findings don't apply to Type 1, a different condition that appears to be on the rise and that is not caused by obesity or lifestyle factors. Rather, Type 1 diabetes results from an autoimmune destruction of the insulin-producing cells of the pancreas.

And while Type 2 diabetes is linked to obesity and can typically be managed with diet, physical activity, and various medications including insulin for some, Type 1 always requires insulin treatment, either with multiple daily injections or an infusion pump, and is far more labor-intensive to manage.

Type 1 is believed to make up roughly 5 percent of the total 29 million adults and children in the U.S. who currently live with diabetes, or about 1.5 million people. But, the actual number isn't really known, and some surveys have suggested there may be twice that many.

The new CDC numbers came from the National Health Interview Survey (NHIS), which asked adult respondents whether a health professional had ever told them they have diabetes. The survey doesn't ask what type.

This is a problem, according to officials with the T1D Exchange, a nonprofit organization that includes a clinic network, registry, biorepository, and online patient community. In an open letter to the CDC, the Exchange's executive director Dana Ball and chief medical officer Dr. Henry Anhalt called for clarification of the announced decrease in new diabetes cases.

"Comingling of the data, particularly from the leading national public health institute of the United States, perpetuates the myth that diabetes is one disease sharing a name, while the reality is that Type 1 and Type 2 diabetes are actually two different diseases in the diabetes family," Ball and Anhalt wrote.

One concern, Anhalt told Shots, is that scientists seeking funding for research into Type 1 diabetes might be turned down if the condition is perceived to be on the decline, when in fact the opposite appears to be the case.

Most of the available data on Type 1 diabetes are in children, even though a large proportion of people with the condition are adults who developed it either as children or in adulthood.

In a large multisite study called SEARCH for Diabetes in Youth that is jointly funded by the CDC and the National Institute of Diabetes and Digestive and Kidney Diseases, there was a 21 percent increase in the number of new cases of Type 1 diabetes in children between 2001 and 2009. Increases were seen in kids of all ages, as well as in ethnic or racial minority groups that are more commonly associated with Type 2.

And according to the International Diabetes Federation's Seventh Atlas , released in 2015, the number of kids with Type 1 diabetes worldwide had risen 9 percent since the Sixth Atlas, from 2013.

Researchers don't know why Type 1 diabetes is rising, and it's important to find out, Anhalt said. "The call to action was not necessarily to say CDC is bad. But if you don't have a way to do it, find one, because obtaining those data is vital."

But that's not so easy, says Edward Gregg, chief of the Epidemiology and Statistics Branch in the CDC's Division of Diabetes Translation. "Our national survey data unfortunately don't have the detail necessary to accurately distinguish diabetes types," he told Shots.

For one thing, while the majority of adults with diabetes in the U.S. have clear-cut Type 2, many aren't familiar with the terminology or are confused about it. Because T1 used to be called "insulin-dependent" diabetes, some people still mistakenly believe that anyone treated with insulin has Type 1. In fact, between a quarter and a third of people with Type 2 are treated with insulin, typically after they've had the condition for several years.

And the former terms "juvenile" and "adult-onset" diabetes persist despite having been officially changed to Types 1 & 2 nearly 20 years ago, after it became clear that adults could develop the "juvenile" type. And Type 2 is now appearing in some overweight and obese children, particularly among African-American, Hispanic or Native American teenagers.

"When you survey people in the population you could ask them their type, but it would not be a super-accurate way of determining the prevalence," Gregg noted.

Health care providers are confused too. Some will simply diagnose all new-onset diabetes in adults as Type 2, since it wasn't appreciated until recently that Type 1 can and often does first appear in adults in their 20s, 30s, 40s, and even older. (Because Type 1 onset tends to be slower in adults, it's often called "latent autoimmune diabetes of adulthood," or "LADA.")

And for pediatricians, it may be difficult to tell which diabetes type an overweight or obese child or teenager has.

Indeed, the overall rise in obesity has furthered the diagnostic confusion. People with Type 1 were generally thin in the past, but today that's no longer the case (in the developed world, anyway).

Although obesity isn't the driver of Type 1 diabetes as it is in Type 2, people with Type 1 diabetes today are at least as likely to be overweight or obese as the general population. And with that, they may also display similar heart disease risk profiles as do people with Type 2 diabetes – in fact, heart disease is believed to be the number one killer of people with Type 1 diabetes, as it is for Type 2.

Adding to the confusion, there are other genetic types of diabetes that are also commonly misdiagnosed as either Type 1 or Type 2. Some of those people are put on insulin unnecessarily, making them vulnerable to weight gain and potentially dangerous low blood sugar episodes.

While some laboratory tests can help determine diabetes type, none are perfect and the most accurate one – checking for antibodies associated with Type 1 diabetes – is not routine and can be costly. (The genetic tests are even more expensive.)

Endocrinologist M. Sue Kirkman, a professor of medicine at the University of North Carolina, Chapel Hill, doesn't ask diabetes patients about their type. Instead, she asks about factors such as their age and symptoms at diagnosis, medication history and family history of diabetes.

"There's a lot of confusion, Kirkman says. "It's not infrequent to see medical records that say Type 2 diabetes, but when we ask the patient some of those questions it's clearly Type 1." And if the type still isn't clear, she'll order an antibody test.

While some argue that knowing the type may not matter as long as the person's blood sugars are well-controlled, mix-ups can have serious consequences. For example, in adult hospital settings, where Type 2 diabetes is extremely common, the fact that insulin can't be withheld for long periods of time – such as for a surgical procedure - in Type 1 patients may be overlooked, Kirkman notes.

Besides, she says, "I actually think it's important for people to understand what kind of diabetes they have, even if [their current treatment] is working. I think it's important to be educated about what's wrong with your body."

Kirkman agrees with the T1D Exchange that CDC should work to improve its data gathering. "I hope the CDC can in the future distinguish better, because I think it's really important to know what's going on with one and the other."

In fact, Gregg says, CDC is addressing the issue in several ways. His team has developed new questions for the NHIS aimed at better distinguishing between the diabetes types, including the age at diagnosis, the interval between diagnosis and starting insulin (a short time would suggest Type 1), and whether insulin use was ever stopped (a long period without insulin would suggest Type 2).

Those questions are being field tested, he said, noting that "we'd be getting a better estimation of proportion of Type 1 versus Type 2, although it won't be perfect."

And, in addition to co-funding the SEARCH study, which looks at both Type 1 and Type 2 diabetes in youth, CDC has also recently issued a request for applications for research specifically to investigate rates of Type 1 diabetes in young adults, with a due date of February 23rd. "That would also hopefully fill this data gap," Gregg said.

Meanwhile, some diabetes experts say that it's time for a complete overhaul of the way diabetes is classified by basing it on underlying causes rather than potentially misleading descriptive characteristics.

In a perspective published last week in the American Diabetes Association journal Diabetes Care, the authors wrote, "The current classification system presents challenges to the diagnosis and treatment of patients with diabetes... in part due to its conflicting and confounding definitions of Type 1, Type 2, and [LADA]...We urge that the time is right to convene a committee of diabetes community leaders and researchers to reevaluate the current outmoded [diabetes] classification system."

Miriam E. Tucker is a freelance journalist specializing in medicine and health. You can follow her on Twitter @MiriamETucker.

Copyright 2016 NPR. To see more, visit NPR.
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Fight To Lower Drug Prices Forces Some To Switch Medication

NPR Health Blog - Mon, 01/25/2016 - 5:10am
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Tim Kilroy runs a business from his home in Arlington, Mass. His insurance company quit covering the long-acting Ritalin that helps him manage his ADHD.

Ellen Webber for NPR

Steve Miller has some customers on offer. Millions of them in fact.

The chief medical officer at Express Scripts, the largest pharmacy benefit manager in the U.S., has been essentially auctioning off his 80 million customers to the drug companies that will give him the best deal.

"Who wants my market share?" Miller says. "Whoever will give me the best price, I will reward you with an enormous amount of market share."

Miller is the most vocal leader in what has become a war on drug prices.

Express Scripts and its rivals including CVS/Caremark and OptumRX manage prescription drug coverage for insurers and employers. They're trying to spark price wars among drugmakers by refusing to pay for some brand-name medications unless they get a big discount.

The result is that average costs for many drugs are falling. At the same time, consumers are being forced to change medications, sometimes to brands that don't work as well for them.

Tim Kilroy is a father of five who runs a business out of his home in Arlington, Mass. Kilroy has attention deficit hyperactivity disorder — ADHD — and he is dependent on his medications to keep his mind, and therefore his business and family life, in order.

"I had tried several drugs," he recalls. "I had tried Concerta; I had tried Adderal. Finding the right dosage can be really challenging."

He spent six years trying medications, adjusting doses, switching and starting over before he and his doctor settled on a long-acting form of Ritalin. He'd finally landed on the drug that worked for him. But about a year ago he switched insurance and the new pharmacy benefit company — United Health Care's Optum subsidiary — refused to pay.

"I thought, 'How dare you,' " Kilroy says. "How dare this company that I pay money to tell me how to manage my health care. I was really, really angry."

He paid for the Ritalin once, but it cost more than $120 a month on top of his insurance premiums. So he asked his doctor to move him to another medication that was covered. Kilroy says it does a good job controlling his ADHD, but the side effects include a swollen prostate that makes it difficult to urinate. So now he's switching insurers again so he can get back on Ritalin.

Kilroy is just one of millions of people affected by this battle between drug companies trying to make as much money as possible and insurers trying to drive down those prices. This year, more than half of all people with insurance will have some medications excluded from coverage, says Ronny Gal, a drug industry analyst at investment firm Alliance Bernstein in New York.

"Drug companies have been pricing their drugs largely along the lines of, you know, whatever you can get away with and still have the patient get the drug," he says. "This year exclusion will become a standard feature of the industry, which is actually quite a shocker for a lot of patients."

Express Scripts pioneered the strategy two years ago, when it announced it would no longer pay for 48 brand-name drugs. Right out of the gate it took on some big-name products, such as Advair — the blockbuster asthma drug made by GlaxoSmithKline, now known as GSK.

Advair's price had risen more than 20 percent in 2013, according to data from SSR Health, a New Jersey-based investment research firm. Then on Jan. 1, 2014, Express Scripts tossed Advair off its drug list and moved its customers to rival asthma drug Symbicort.

The results were immediate. Sales of Advair dropped $1.8 billion that year. The prices of both Advair and Symbicort fell 20 percent in 2014 and are still falling. GSK spokeswoman Jenni Ligday said in a statement that Advair was restored to Express Scripts' formulary last year.

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Express Scripts isn't alone. Caremark, Optum and Prime Therapeutics also refuse to pay for some name-brand medications. Dr. David Lassen, the chief medical officer at Prime, which is the pharmacy benefit manager for several Blue Cross and Blue Shield plans, says the company offers an exclusion option to its health plan customers.

He says insurers are knocking drugs off their coverage lists because drug companies have undermined their other efforts to contain costs. In the past, insurers would charge a high copay for expensive drugs to steer customers to cheaper alternatives.

"The pharmaceutical companies have developed member coupons, and many times those coupons wipe out the members' copay for them," Lassen says. "It really kind of circumvents the intended benefit design."

The strategy of refusing to pay for some medications has forced drug companies to offer deep discounts on medications that have competition, according to analyst Richard Evans of SSR Health. While list prices for drugs have continued to rise, Evans wrote in a September report that after discounts drug prices rose only 0.7 percent in the second quarter of 2015 compared with a 4.4 percent increase in the same quarter a year earlier.

For many customers, the changes are a small inconvenience. They have to call their doctors and ask for a prescription for a new brand of painkiller, acne medicine or asthma inhaler. The alternatives often work fine.

But that's not always the case, as Kilroy's situation illustrates.

Oncologist Barbara McAneny, immediate past chairman of the American Medical Association, says very few chemotherapy drugs are excluded from approved drug lists. But the medications used to help patients get through chemo, like painkillers and hormone treatments, are. This complicates her ability to care for her patients.

"Some patients will tolerate one pain medicine, for example, but not another," she says. "One can cause nausea and the other pain medicine doesn't."

If a medication is working, McAneny says it's totally inappropriate for anyone to change that medication and cause the patient to have symptoms.

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